Case Study Exam 1
Case Study Exam 1
Case Study Exam 1
What data is RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT data from HPI: Rationale:
-Need to know what surgery was done with what approach to assess postoperatively,
-Chronic back pain, posterior spinal fusion,
need to establish baseline pain and pain medications in order to make pt comfortable
Oxycontin 40 mg bid at home, Dilaudid PCA,
Settings: 0.2mg continuous, 0.1 mg bolus
every 10 with a 4 hour max of 6 mg,
increased pain, increased bolus by 0.2 mg
What assessment data is relevant that must be recognized as clinically significant to the nurse?
RELEVANT assessment data: Rationale:
-Lethargic, Unresponsive, ashen pale in color -Pt too sedated to turn his head when needing to vomit and aspirated emesis into his
-Minimal spontaneous respiratory effort lungs.
-Mouth full of liquid emesis drooling out of -Obstructed airway has caused his body to have lack of oxygen leading to lethargy and
mouth unresponsiveness.
-Pulse of 24 bpm -Due to lack of oxygen in his system his heart cannot keep up with the demand to pump.
-BP: low>too low -Blood Pressure has decreased because the heart is not pumping and therefore
cardiac output has significantly decreased.
-O2 Sats: low>too low -O2 sats are low because of obstructed airway and the inability for the pt to breathe in
O2.
-The pt has aspirated emesis into his lungs and obstructed his airway.
-The pt was too sedated to be able to turn his head or move when he vomited so he aspirated emesis that is
obstructing his airway.
-The lack of O2 in his system has caused him to go into cardiac arrest.
-First an airway needs to be established. Raise the HOB and suction his mouth with a yankauer to prevent any
more aspiration of emesis.
-Second call a rapid response or code blue. Whatever is necessary to get more hands there.
4. Nursing Interventions: (identify clinical & BLS priorities-place in order to best rescue)
Nursing Interventions: Rationale: Expected Outcome:
1. Call a Code Blue 1. To get extra help there ASAP Pt will have a patent
2. To get resuscitation equipment airway and O2 will
2. Call for a Code Cart there circulated through
A : To get rid of the airway obstruction the vascular system.
Airway Priorities: Clear airway of emesis
Circulatory Priorities: Get the heart back to C: To circulate blood through the body
pumping blood that the heart cannot right now.
Breathing Priorities: Get O2 in and out of B: Get O2 to the organs like the heart to
the body prevent ischemia and permanent
damage.
Circulatory Priorities: Use compressions C: Circulate oxygenated blood to feed
to circulate that O2 and get the heart vital organs
pumping again
7. What nursing assessment(s) will you need to initiate to identify and respond if this complication
develops?
- Cardiovascular and respiratory assessments with need to be done.
A crash cart is brought into the room, and is placed on the cardiac monitor/defibrillator. The following
rhythm is displayed:
Interpretation: V-Fib
Ten minutes into the code, after one dose of Epinephrine and Amiodarone and the third defibrillatory shock at
360 joules, the following rhythm is present on the monitor:
Interpretation: SVT
Clinical Significance: Now there is a sinus rhythm but is at a very fast rate. We need to slow the rhythm down to be able
to perfuse the entire body.
What is the FIRST thing that the nurse should do if this rhythm is present?
VS:
T: 99.1 (o)
P: 128 reg
R: ambu at rate of 12/minute
BP: 128/88
O2 sats: 92% ambu bag
Nursing Assessment:
GENERAL APPEARANCE: Color slightly improved. Is pale/pink
RESPIRATORY: Coarse crackles/rhonchi scattered in both lung fields even after suctioning. No spontaneous
resp. effort. Requires ambu bagging
CARDIAC: Pulses 2+ throughout. Strong femoral pulse. No edema in extremities. Heart rate regular-S1S2.
NEUROLOGIC: Remains unresponsive. Responds to pain stimuli by bringing both hands towards the source
of pain
ABDOMEN/GI: Abdomen soft, non-tender with active bowel sounds
1. Has the status of the patient improved or not as expected to this point?
- The pt has a patent airway and is now has good perfusions so that is as expected. The pt should have
never gotten to this point, but the outcome of the rapid response is as expected.
3. What is the rationale for the changes in your patients status that you have seen to this point?
- Intubating established a patent airway. CPR and medications perfused the pts organs while the airway
was being established. Color has improved due to the improvement of oxygenation. The strong pulses
throughout are due to perfusion being reestablished.
4. Based on your current evaluation of your patient, what are your nursing gaols/priorities and
plan of care? Think ABCs
A-Airway
- Maintain a patent airway via ET tube.
B-Breathing
- Improve respiratory status and administer antibiotics as ordered because of aspiration. Will most likely
have aspiration pneumonia.
C-Circulation
- Monitor ECG carefully to make sure the heart is able to do an adequate job and perfuse.
- Maintain a Blood Pressure with a MAP above 65.
- Maintain peripheral pulses of at least 1 +.
Identify the relevant lab results to this patient and their clinical significance?
- Hemoglobin in low most likely due to his blood loss during his spinal fusion.
- Neutrophils being high and Lymphocytes being low are part of the inflammatory response the body is
having to the trauma it just went through.
- Expect WBCs to go up with those lung infiltrates.
It is now time to transfer to ICU. Effective and concise handoffs are essential to excellent care and if not done
well can adversely impact the care of this patient. You have done an excellent job to this point, and have
RESCUED your patient, now finish strong and give the following SBAR report to the nurse who will be caring
for this patient in the ICU:
Situation:
- Mr. Williams was over sedated when he had some emesis that he aspirated into his lungs. We called
a rapid response because his breaths were 4 per minute pulse of 24. We suctioned and ended up
coding him. He was V-fib so we shocked him, gave epi, and gave amiodarone before we got him
back at sinus tach which is what he is in now. He was intubated and should be getting hooked up to
the vent and showing signs of improved respiratory status.
Background:
- He is post-op from a lumbar spinal fusion today L5-S1. He has chronic pain and was on a Dilaudid
PCA. He normally takes Oxycontin 40mg bid at home. He was having nausea and emesis.
Assessment:
- We checked placement of the ET tube it is good position. His ABGs are showing improvements. His
lungs have crackles/ronchi scattered in both lungs. He is at 100% oxygen delivery. He is in sinus
Tach with good peripheral pulses. He is still sedated and only responsive to painful stimuli. Since he
has been back from surgery I have not looked at his dressing and that should be addressed.
Recommendation:
- If mechanical ventilation has not already been initiated do so. Monitor sedation and administer
sedatives if pt becomes aware enough to pull ET tube. Start some antibiotics for the lung infiltrates
that were aspirated. Monitor ECG and BP closely. Pt should stay here in ICU until status improves.